<<

MEDICAL HISTORY FORM

Patient Name: ______DOB: ______/______/______

Signature: ______Date: _____/______/______

Present Health Concerns: ______

Please list all prescription and non-prescription , : : List all reactions to medicines, foods and other agents. vitamins, home remedies, birth control pills, herbs etc. Name Dose Frequency Reaction or Side Affect

** If you are on 3 or more medications – please bring them with you to each appointment. **

PERSONAL MEDICAL HISTORY: Please indicate whether you have had any of the following medical problems.

Congenital Disease: Cancer (Malignancy) Hepatitis A, B, or C (specifiy)______please specify:______please specify:______Date of Last Colonoscopy: ______Myocardial Infarction (Heart Attack) Date of last Tetanus Shot: ______Hypertension (High ) Coagulation (Bleeding/Clotting) Date of last HIV Test: ______Diabetes Depression/Suicide Attempt Date of Blood Transfusion: ______High Cholesterol Alcoholism Other:______

SURGICAL HISTORY: Please list all prior surgeries and dates. Surgery Date

IMMUNIZATIONS: Please list your most recent immunizations, not including those administered at Lowell General Hospital. Please include your best estimate of the month and year of each immunization.

Hepatitis A: ______Measles: ______Mumps: ______Rubella: ______MMR: ______Hepatitis B: ______Pneumovax: ______Tdap: ______Varicella: ______Other: ______

WOMEN’S HEALTHY GYNECOLOGIC/OBSTETRIC HISTORY: (For Women Only)

# of Pregnancies: _____ # of Deliveries: _____ # of Abortions: _____ # of Miscarriages: ____ Age at 1st menses: ___ Frequency of menses: ______Length of menses: _____ Date of last menses: ______Date of last mammogram: ______

Do you have any concerns about your period or menopause? □ Yes □ No Please explain: ______Have you ever had an abnormal pap smear? □ Yes □ No If circled yes, when was it? ______

Page 1 FAMILY HISTORY: Please indicate with a check (√) who in your family has had the following conditions. In the first column please indicate their living status. L = Living, D = Deceased, U = Unknown.

High Living Asthma Diabetes Blood Heart Stroke Heart Cancer Colon Depression Other Status Pressure Disease Attack (Type) Polyps Mother Father Siblings Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Other Family Members Information: (please write in)

SOCIAL HISTORY: Exercise: Drug Use: Alcohol Use Do you exercise regularly? □ Yes □ No Do you use any recreational drugs? Do you drink alcohol? □ Yes □ No Tobacco Use: □ Yes □ No If yes, # of drinks per week: ______□ Current □ Never □ Former: quit on: ______If yes please list ______What type of alcohol: ______*If current # of packs/day ___ # of years ____ If you have used in the past, how long Is alcohol a concern for you or others who Other Tobacco: □ Pipe □ Cigar □ Snuff □ Chew have you been drug free? ______surround themselves around you? Are you interested in quitting? □ No □ Yes Have you ever used needles for IV drug □ Yes □ No use? □ Yes □ No SAFETY SOCIOECONOMICS Do you wear a seatbelt regularly? □ Yes □ No Have you ever been physically or sexually Occupation:______Do you wear a bike helmet regularly? abused? □ Yes □ No Degree of education completed:______□ Yes □ No Do you have a gun in your home? Marital Status: ______Do you feel safe at home? □ Yes □ No □ Yes □ No Spouse/Partner’s Name: ______Do you feel safe in your current relationship? Are you a member of a gang? □ Yes □ No Who lives at home with you? ______□ Yes □ No Other concerns: ______

SEXUALITY Other Services Are you sexually active? □ Yes □ No Birth Control Method: ______Have you had a recent eye exam? □ Yes □ No Current sex partner(s) are: □ male □ female Have you ever had a sexually transmitted Have you had a recent dental exam? If sexually active do you practice safe sex? disease? □ Yes □ No □ Yes □ No □ Yes □ No If yes, please include: ______Do you see any other specialists? ______Other Concerns: ______Are you interested in being screened for ______sexually transmitted diseases? □ Yes □ No ______

EMOTIONS In the past year, have you had 2 or more weeks during which you felt sad or depressed; or you lost all interest or pleasure in things that you usually cared about or enjoyed? □ Yes □ No Have you had 2 or more years in your life when you felt depressed or sad most days, even if you felt okay sometimes? □ Yes □ No Have you felt depressed or sad much of the time in the past year? □ Yes □ No Do you ever feel like hurting yourself of others? □ Yes □ No

Page 2 : Please indicate with a check (√) any current problems you have below.

Constitutional Eyes Musculo-skeletal Fevers/chills/sweats Changes in vision Muscle/joint pain Unexplained weight loss/gain Farsighted Arthritis Fatigue/weakness Nearsighted Other: ______Excessive thirst or urination Other: ______Other: ______Neurological Gastrointestinal Headaches Cardiovascular Abdominal pain Dizziness/light-headedness /discomfort Blood in bowel movement Numbness Leg pain with exercise Nausea/vomiting/diarrhea Memory loss Heart murmur or heart problems Other: ______Loss of coordination Palpitations ______Epilepsy or convulsive seizures Other: ______Other: ______Genitourinary Nighttime urination Chest Incontinence Psychiatric Breast lump/discharge Sexual function problems Anxiety/stress Other: ______Discharge from penis Problems with sleep ______Other: ______Depression ______Suicidal ideations Other: ______Ears/Nose/Throat/Mouth ______Difficulty hearing/ringing in ears Gynecological Hay fever/allergies Abnormal vaginal bleeding Problems with teeth/gums Problems with conceiving Respiratory Difficulty swallowing Problems with contraception Cough/wheeze Difficulty with speech Vaginal discharge Difficulty breathing Other: ______Vaginal odor Asthma ______Painful intercourse COPD Other: ______Sleep apnea ______Other: ______Endocrine ______Hypothyroid Hyperthyroid Lymphatic/Blood Abnormal hormone levels Unexplained lumps Skin Abnormal blood glucose levels Easy bruising/bleeding Rash or mole change(s) Other: ______Anemia Psoriasis ______Other: ______Eczema ______Other: ______

Page 3